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Information Sharing and Public Private Partnerships: Responding to 2009 H1N1

Pandemic

Aaron DeVries, MD MPH Medical Director, Infectious Disease Division

Minnesota Department of Health

1

April 1, 2009

http://www.jornada.unam.mx/ultimas/2009/04/01/veracruz-reporta-agente-municipal-extrano-brote-epidemico-que-ha-cobrado-dos-vidas

Death

Critical Illness

Hospitalization

Moderate Outpatient Illness

Mild Outpatient Illness

Minimal or No Symptoms

1. Deaths with infectious hallmarks

2. Hospitalized patients with ILI

3. Virology Lab Reporting

Influenza Disease Burden

MDH Influenza Surveillance – Case Based

6. School Absenteeism

5. Longterm Care Facility ILI

4. Sentinel site ILI

1. Deaths with infectious hallmarks

2. Hospitalized patients with ILI

3. Virology Lab Reporting

6. School Absenteeism

5. Longterm Care Facility ILI

4. Sentinel site ILI

Influenza Disease Burden

MDH Influenza Surveillance – Non-Case Based Death

Critical Illness

Hospitalization

Moderate Outpatient Illness

Mild Outpatient Illness

Minimal or No Symptoms

Hospitalized Cases of Influenza by Influenza Type, Minnesota, October 1, 2008 – March 27, 2010

2008-2009 influenza season

2009-2010 influenza season 2nd H1N1 wave

Summer surveillance 1st H1N1 wave

1st H1N1 hospitalized

case

0

25

50

75

100

125

150

175

200

225

250

275

300

325

350

375

400

425

450

Month/Year of Specimen Collection

Num

ber o

f Hos

pita

lizat

ions

A/B (rapid test only) B (rapid test only) A (rapid test only) Seasonal B Untypeable A Novel H1N1

Seasonal A

Novel A H1N1 Hospitalizations per 100,000 PersonsMinnesota, April 1, 2009 - January 30, 2010

0

2

4

6

8

10

12

14

17-18

19-20

21-22

23-24

25-26

27-28

29-30

31-32

33-34

35-36

37-38

39-40

41-42

43-44

45-46

47-48

49-50

51-52 1-2

MMWR Week of Specimen Collection

Hos

pita

lizat

ions

per

100

,000

per

sons 7-county MSP Greater MN

“Summer wave”

“Fall wave”

Smoothed lines

Schools Reporting Outbreaks of ILI, Minnesota, September 2009 - February 2010

0

50

100

150

200

250

300

350

35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10

Week of Outbreak

Num

ber o

f Sch

ools

0%

5%

10%

15%

20%

25%

Number of Schools Reporting

Percent of Eligible Schools Reporting

Proportion of Patients with ILI, Sentinel Outpatient Sites by Season, Minnesota, September 2009 – February 2010

0

1

2

3

4

5

6

7

35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Week of Clinic Visit

% o

f Out

patie

nts

with

ILI

07-08 Season08-09 Season09-10 Season

http://www.health.state.mn.us/divs/idepc/diseases/flu/stats/index.html

Reports to MDH from Health Care Facilities

• Clinic offices and emergency rooms were at peak capacity – Both sick and worried well

• Concern about transmission in crowded health care facilities • People at increased risk for complications were

encountering delay in receiving treatment • Un- and under-insured not receiving treatment

– Retail cost ~$92 oseltamivir treatment course

• Existing nurse triage lines/health care systems were providing differing recommendations and services

• Surge options were needed – 2nd and 3rd wave of illness

MDH Challenges • Vaccine was weeks/months away • Large stock of MN and federal purchased

antivirals • High priority

– Maintaining a sustained response – Un- under-insured – Rapid treatment when needed – Ensuring a supply for those who were unable to

get antivirals through usual supply chain

Development of MN FluLine

• Multiple evaluation/distribution models discussed – An infection preventionist at a children's hospital

approached MDH with the idea for an integrated Nurse Triage Lines (NTL)

• Nurse triage line seemed to be the most effective and quickest to operationalize – Rapid evaluation – Target high risk groups – Recommend level of care (home vs clinic vs ER) – Recommend antiviral if home care advised

Private Health Partners: All MN health systems with an NTL

17

FluLine Single Point of Contact

Development of Partnerships

• MDH contacted all health care systems with an NTL – All agreed to coordinate NTL services – Provide an integrated NTL with a single toll free number – Standard protocol for evaluation – NTL would prescribe oseltamivir via protocol when

indicated and call in a script to a local pharmacy – Pharmacies separately contracted with MDH to distribute

state stockpile meds • Communication tools

– Multiple (daily) conference calls, in-person meetings – NTL decision makers and Medical Directors

• Vendor was identified to operate system • Named Minnesota FluLine

18 Public Health Rep, 2012; 127: 532-40

Sept Oct Nov

First MDH discussion on NTL

2009

First conference call with health plans

21

MN FluLine Launch and Press Conference

Protocol Development

NTL provider contract work

Pharmacy contract work

Antiviral placement in pharmacies

NTL training

Timeline of FluLine Development

Callers to 1-866-259-4655

Medical Screener Contract Provider

Not ill, not exposed - Information only

• 211 • MDH public hotline • Websites (MDH, CDC, Mayo) • Other community resources

Ill or exposed to someone with ILI

MN FluLine System Design


Callers to 1-866-259-4655

Medical Screener Contract Provider

Not ill, not exposed - Information only

• 211 • MDH public hotline • Websites (MDH, CDC, Mayo) • Other community resources

Ill or exposed to someone with ILI

Health plan participating in the MN

Flu Line

Partner administers MDH protocol

MN FluLine System Design

No insurance or health plan not participating in

MN FluLine

Contractor administers MDH

protocol


MDH Protocol

Home Care Only Home Care AND Antiviral indicated

Call MD Go to ED Call 911

Clinical Evaluation

See MD


MDH Protocol



Clinical Evaluation

See MD

RN prescribes per protocol

Retail Pharmacy dispenses

Market Supply Insurance billed

State and Federal Stockpile

• Uninsured • Underinsured • Market interruptions

Antiviral Distribution


FluLine Data • Reported 1-3 days to MDH

– Total call numbers to the toll free number – Call numbers managed by our contractor where the

medical protocol was administered

• Not reported timely – Data on calls transferred to partner NTLs – Demographics, severity of illness of callers – Number accessing state oseltamivir stockpile – Clinical outcome – Satisfaction with service – Collected from a sample of callers during program

evaluation after completion

26

Week of Specimen Collection or MN FluLine Call

Num

ber o

f Hos

pita

lizat

ions

0

50

100

150

200

250

300

350

400

34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Cal

ls to

MN

Flu

Line

Sept Oct Nov Dec Jan Feb Mar

Minnesota Hospitalized PCR-Confirmed 2009 H1N1 Cases and Calls to MN FluLine, Sept. 2009 – February 2010

2009 H1N1 Hospitalizations

Calls to MN FluLine

2009 2010

Public Health Rep, 2012; 127: 532-40 27

Public Health Rep, 2012; 127: 532-40

MDH Protocol N=5,949



Clinical Evaluation

See MD

2,292 (39%) 374 (6%) 1,292 (22%) 875 (15%) 122 (2%)

Other

496 (8%)

497 (8%)

39%

6% 8%

22%

15%

2% 8%

3,659 (62%) were recommended to NOT seek in-person care

Impact • Over 27,000 individuals called (0.5% of Minnesotans)

– Over 17,000 needed information only – Median age of patient - 22 years – Callers were from 86 counties – 14% had no insurance coverage (MN uninsured rate in 2009 - 9%)

• Highest call volumes per capita were in predominantly rural, northeast MN

• Up to an estimated 11,000 in-person health care encounters prevented

• 92% were satisfied or very satisfied with their experience • Contract cost of MN FluLine service was $331,226

30 Public Health Rep, 2012; 127: 532-40 PLOS ONE, 2013, 8(1): e50492. doi:10.1371/journal.pone.0050492

Lessons Learned • Telephonic triage can have a major impact on decompressing

the healthcare system • Leverage existing infrastructure

– Health plans and healthcare delivery organizations wanted to keep their own patients

– Nurse triage in MN was well established – Pharmacists could have performed the same function

• System was designed for clinical service and not data collection. If more time and planning: – Realtime numbers of callers and their clinical presentation – Geo-location, demographics – Outcome of those who had the protocol administered

31

Lessons Learned • Data collection was a direct cost to our vendors

– Type and amount of data collected was addressed in contract

– Prioritize each data point collected

• Over estimate the service use during a time of crisis • Find decision makers as quickly as possible

– Getting prescriber buy-in on the protocol was critical

• Engagement with pharmacies earlier – Distribution fee – Burden of documentation required

• Legal framework in MN is not typical 32

Acknowledgements Minnesota Department of Health • Dr. Ruth Lynfield • Commissioner Dr. Sanne Magnan • Alison Spaulding • Deb Radi • Michelle Larson • Craig Acomb • Legal Unit Staff • Infectious Disease Division Staff • Office of Emergency Preparedness Staff

Children’s Physician Network • Heather Macleod • Dr. Peter Dehnel • Terri Hyduke • Nursing and triage staff

Children’s Hospitals and Clinics • Patsy Stinchfield

University of Minnesota • Dr. John Nyman • Dr. Judith Garrard • Dr. Eileen Harwood

Centers for Disease Control and Prevention • Dr. Alex Kallen • Dr. John Jernigan • Public Health Emergency Response Grant • Influenza Division • Emerging Infections Program

Health Care System Partners • Blue Cross and Blue Shield of MN • Children’s Hospitals and Clinics of MN • Children’s Physician Network • Fairview Health Service • HealthPartners • Mayo Clinic • Medica • Metropolitan Health Plan • OptumHealth • Park Nicollet Health Services • Prime West Health • Saint Mary’s Duluth Clinics • UCare • United Way 211

33

Questions?

[email protected]

34

Legal Framework • Existing MN legal framework allowed this activity

– A licensed practitioner may prescribe without reference to a specific patient via a protocol administered by a nurse, medical student, physician assistant, or pharmacist – MN Statute 151.37

– Supported by MN Mass dispensing authority – MN Statute 144.4198

– All partner Nurse Triage Lines had a medical director who already approved their protocols

35

Legal Framework (cont.) • Improving buy-in from non-governmental partners

– Allow all medical directors of partner NTL’s to edit the protocol – became a consensus document

– Federal public health emergency declaration – PREP Act – State Epidemiologist and Medical Director signed the

protocol under the delegated authority of the Commissioner of Health (also a physician)

– Coordination with the Board of Pharmacy

36

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